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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006126
Report Date: 03/25/2025
Date Signed: 04/04/2025 08:09:42 AM

Document Has Been Signed on 04/04/2025 08:09 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:RDB GUEST HOMEFACILITY NUMBER:
306006126
ADMINISTRATOR/
DIRECTOR:		BANGGALAT, REGIE DANCELFACILITY TYPE:
740
ADDRESS:2351 W. BROADWAYTELEPHONE:
(714) 519-5268
CITY:ANANHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6CENSUS: 6DATE:
03/25/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Bonifacio Briones, House ManagerTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Bonifacio Briones, House Manager at 1pm.

The facility is a single story residence with three resident bedrooms and one staff bedroom. The facility has an approved fire clearance of five non-ambulatory residents of which one may be bedridden and a hospice waiver for six. The facility currently has a census of six residents in care.

During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperature in two of two resident bathrooms, and testing auditory devices on all exits. The hot water temperature measured between 117.8 and 127.0 degrees Fahrenheit and a Type A deficiency will be cited. House Manager was advised to lower water heater temperature and to secure cleaning products in the main bathroom cabinet. All smoke detectors were operational. The fire extinguisher is charged and was serviced on September 13, 2023. The facility did not have a fire drill on file.

LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. The weekly menu was posted on refrigerator. LPA observed medication storage and reviewed the centrally stored medications. Per review medications are being given as prescribed. The First Aid kit has all the required elements but did not have a First Aid book.

(Continued on LIC 809-C)
NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: RoseMarie Ruppert
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/25/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: RDB GUEST HOME
FACILITY NUMBER: 306006126
VISIT DATE: 03/25/2025
NARRATIVE
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(Continued from LIC 809)

LPA toured the exterior of the facility and observed a shaded seating area and ample room for outdoor activities. There are no hazards or obstacles in exterior passageways. All storage units were locked.

LPA reviewed three of three staff training and fingerprint records and conducted a complete review of resident records. LPA requested to see bedrail orders for five of six residents but none were on file in physician's orders or hospice orders. Three of six resident records did not have a medical assessment or appraisal needs and services plan. A sixth resident recently moved in within a week and only had a hospice file. Type B deficiencies will be given regarding documentation.

LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has a current administrator certificate which expires on March 17, 2026.

The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations.
An exit interview was conducted with Bonifacio Briones, House Manager and a copy of this report was given to the facility along with a copy of the LIC 858, LIC 859; LIC 809-D and Appeal Rights.
NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: RoseMarie Ruppert
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2025
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 04/04/2025 08:09 AM - It Cannot Be Edited


Created By: RoseMarie Ruppert On 03/25/2025 at 03:39 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: RDB GUEST HOME
FACILITY NUMBER: 306006126

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(3)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation the licensee did not comply with the section cited above in one of two resident bathrooms which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/26/2025
Plan of Correction
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Staff will lower water heater temperature and will email or contact LPA with photo documentation that the main bathroom water temperature is between 105 to 120 degrees Fahrenheit. Staff will also post signage stating water temperature is currently over 125 degrees Fahrenheit.
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in one of two resident bathrooms which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/26/2025
Plan of Correction
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House Manager will immediately remove cleaning products and disinfectants and store in the locked cabinet beneath the kitchen sink.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
RoseMarie Ruppert
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2025


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 04/04/2025 08:09 AM - It Cannot Be Edited


Created By: RoseMarie Ruppert On 03/25/2025 at 03:39 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: RDB GUEST HOME
FACILITY NUMBER: 306006126

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review and interview the licensee did not comply with the section cited above in three of six resident records which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2025
Plan of Correction
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Licensee (LE) will complete Pre-admissions and Appraisal and Needs Service Plans for three of six resident records by the Plan of Correction Date. LE will email documentation to LPA.
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review and interview the licensee did not comply with the section cited above in three of six resident records which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2025
Plan of Correction
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Licensee (LE) will obtain Medical Assessments for three of six resident records by the Plan of Correction Date. LE will email documentation to LPA.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
RoseMarie Ruppert
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2025


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 04/04/2025 08:09 AM - It Cannot Be Edited


Created By: RoseMarie Ruppert On 03/25/2025 at 03:39 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: RDB GUEST HOME
FACILITY NUMBER: 306006126

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA interview and record review, the licensee did not comply with the section cited above for six of six residents which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2025
Plan of Correction
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Licensee (LE) will conduct a fire drill quarterly including documentation the type of fire drill performed and staff signatures showing participation. LE will email LPA by the Plan of Correction Date.
Type B
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA interview and record review the licensee did not comply with the section cited above in five of six residents which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2025
Plan of Correction
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Licensee (LE) will obtain physician's orders for bed rails for five resident files. LE will email LPA by Plan of Correction Date with bed rail orders.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
RoseMarie Ruppert
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2025


LIC809 (FAS) - (06/04)
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